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� APPLICATION FOR BLIND OR DISABLED PERSON'S
:! . . � DEDUCTION FROM ASSESSED VALUATION
��� State Form 43710 (R / 9-96)
? Prescrihetl by the State Boartl of Ta. Commissioners
.rmation contained in this document is CONFIDENTIAL pursuant ro IC 12-1-1-1(n) and IC 6-1.7-72-72(b).
INSTRUCTIONS FOR FILING: �
To be liled in person c,- by mail with the County Auditor ol the county where the property is loca
ted during the 72 months belore May 17 0l the year the deduction is to be eNective.
See reverse side lor additional instructions and qualilications.
applicant the sole le9al or
name on record is difteren
ame of contrad seiler
idress of contract seller
applicant blind as detined
the property used and oa
�
ucing cjj�ricl ` /'� C �
U 1 J J
��.
I/We certify under pc
dent o( Indiana and �
❑ Yes ❑ No
❑ Yes VNo
❑ No
No, what is his/her exact share of inte
icate below
' � � ��.JII W V M./
t2(b)?
COUNTY TOWNSXIP• Y`2AR
f�' � � !T H �
F'le Iv1a �/
AUG 16 2001
I with someone other than spouse,
with whom
Is applicant disabled and unable to engage in any siantial gainful activiry
as defined in �C 6-1.1-72(d)? e5 ❑ NO
�fG�,�r.(3�-00
gross income for the preceding calendar year
❑ Yes No
Record number Page number
perjury that the above and foregoing information is true and correct and that the applicant was a resi-
the aforementioned property on March 1, 79 �
/..7�I,b.t�- -��.p ""�' .aN.�..
a � /